Trends in inpatient antimicrobial consumption using days of therapy and days of antibiotic spectrum coverage: A nationwide claims database study in Japan

INTRODUCTION

Days of antibiotic spectrum coverage (DASC), a novel metric for both antimicrobial volume and spectrum, was proposed to measure inpatient antimicrobial consumption in 2022. The DASC may better reflect efforts toward antimicrobial stewardship; however, no previous study has described the distribution of trends in DASC in hospitals or the association between the trend in DASC and days of therapy (DOT). This study assessed trends in antimicrobial consumption for inpatients at acute care hospitals in Japan using the DOT and DASC.

METHODS

This retrospective observational study used the nationwide administrative inpatient claims database of Japanese acute care hospitals between 2014 and 2018. The prescriptions of all antibiotics were identified to calculate DOT/1000 patient-days, DASC/1000 patient-days, and DASC/DOT. We described the five-year trend in these metrics and examined the association between the trends in DOT and DASC.

RESULTS

In total, 26,301,685 admissions from 634 hospitals were included. The DOT/1000 patient-days and DASC/1000 patient-days increased significantly by 6.1% and 5.6%, respectively. The DASC/DOT ratio did not change significantly (P = 0.35). Moreover, there was little correlation between DOT/1000 patient-days and DASC/DOT (R2 = 0.01). There was also little correlation between the five-year changes in DOT/1000 patient-days and those in DASC/DOT (R2 = 0.02).

CONCLUSIONS

It may be difficult to assess trends in the antibiotic spectrum using DASC alone. However, the combination of DOT as a quantity indicator and DASC/DOT as a spectrum indicator may allow for a more appropriate evaluation of stewardship efforts.

A Pancreatic Collision Tumor Comprising Mantle Cell Lymphoma and Adenocarcinoma: A Case Report and Literature Review

A collision tumor is a rare clinical condition where two different tumors occur synchronically within a lesion. Pancreatic collision tumors with mantle cell lymphoma (MCL) are extremely rare and have only been reported in one case to date. We herein report an elderly patient with MCL and adenocarcinoma of the pancreas with Ann Arbor stage IV and Union for International Cancer Control stage IIB, respectively. The patient received palliative therapy and died 23 months after the diagnosis. Further research and case studies are required to investigate whether or not MCL-derived cyclin D1 overexpression affects the occurrence/growth of adenocarcinomas.

Seronegative HIV-1 infection in a Japanese man presenting with Pneumocystis pneumonia: Analysis of long-term antibody response and literature review

Seronegative human immunodeficiency virus (HIV) infection, where an HIV-specific antibody response is lacking even in chronic or late-stage HIV infections, is extremely rare. Here, we report the case of a 50-year-old Japanese man presenting with Pneumocystis pneumonia who did not produce antibodies against HIV-1 until the initiation of antiretroviral therapy (ART). Fourth-generation antigen-antibody testing temporarily reverted from weakly positive to negative soon after initiating ART, likely due to a reduction in viral load (assessed by p24 antigen levels). His HIV-1 antibody titers remained low or indeterminate even after four years of ART. A literature review suggested that the absence of HIV-1-specific antibody production may be associated with unimpeded HIV replication and rapid CD4+ T cell decline. Seronegative HIV infection can lead to deferred diagnosis and treatment, thereby increasing the risk of transmitting the virus to others or developing opportunistic illnesses. It is important to combine multiple tests for diagnosis, depending on the medical condition. Further studies are required to investigate the host factors involved in the production of HIV-1-specific antibodies.

Effect of Inhaled Ciclesonide in Non-Critically Ill Hospitalized Patients With Coronavirus Disease 2019: A Multicenter Observational Study in Japan

Background

Coronavirus disease 2019 (COVID-19) is an ongoing global pandemic. Although systemic steroids play an important role in treating patients with severe COVID-19, the role of inhaled corticosteroids in non-critically ill, hospitalized patients with COVID-19 remains unclear.

Methods

We analyzed findings in non-critically ill, hospitalized patients with COVID-19 who were >18 years old and were admitted to 64 Japanese hospitals between January and September 2020. We performed propensity score matching analysis to evaluate 28-day and in-hospital mortality rates with or without inhaled ciclesonide within 2 days of admission. Sensitivity analyses using inverse probability weighting analysis, and generalized estimating equation method were also performed.

Results

Eligible patients (n = 3638) were divided into ciclesonide (n = 290) and control (n = 3, 393) groups. The 1-to-4 propensity score matching analysis included 271 ciclesonide users and 1084 nonusers. There were no significant differences between the 2 groups for 28-day (3.3% vs 2.3%; risk difference, 1.0% [95% confidence interval, -1.2 to 3.3]) or in-hospital (4.8% vs 2.6%; risk difference, 2.2 [-.5 to 4.9]) mortality rates. The sensitivity analysis showed similar outcomes.

Conclusions

From this multicenter observational study in Japan, inhaled ciclesonide did not decrease 28-day or in-hospital mortality rates in non-critically ill, hospitalized patients with COVID-19. Future large, multinational, randomized trials are required to confirm our results.

Performance of serum soluble interleukin-2 receptor as a diagnostic marker for lymphoma in patients with fever

There have been few reports on the diagnostic performance of soluble interleukin-2 receptor (sIL-2R) for lymphoma. A cross-sectional study was conducted at a university hospital; all patients who were admitted to the Division of General Internal Medicine and underwent serum sIL-2R testing were included. Patients were divided into two groups based on the presence of fever (≥ 38.0 °C). Among 602 patients, 421 had fever and 76 were diagnosed with lymphoma (48 of the 76 were in the febrile group). In all patients, the area under the receiver operating characteristic curve (AUROC) of sIL-2R for the diagnosis of lymphoma was 0.81 [95% confidence interval (CI), 0.75-0.87]. The AUROC was significantly higher in the febrile group (0.88; 95% CI, 0.81-0.94) than in the afebrile group (0.75; 95% CI, 0.65-0.85). In the febrile group, the sensitivity and specificity were 81.2% and 82.3%, respectively, with an optimal cutoff value of 3,250 U/mL. In the afebrile group, they were 89.3% and 54.9%, respectively, with a cutoff value of 868 U/mL. Serum sIL-2R showed high performance as an adjunctive diagnostic marker for lymphoma, particularly among febrile patients. Different cutoff values should be used for patients with and without fever to maximize diagnostic performance.

Regional Variations in Coronavirus Disease 2019 Mortality in Japan: An Ecological Study

Introduction

As the characteristics of coronavirus disease 2019 (COVID-19) vary across regions and countries, the relationship between regional characteristics, such as the distribution of physicians and hospital beds, and COVID-19 mortality was assessed in the 47 prefectures of Japan.

Methods

This ecological study was based on the number of patients with COVID-19 by prefecture during the seventh wave of COVID-19 in Japan (June-October 2022). COVID-19 mortality was indexed as the number of COVID-19 deaths divided by the number of new COVID-19 cases. Data on regional factors, such as population size, number of physicians, and hospital beds by prefecture, were obtained from government statistics. Correlations between regional characteristics and COVID-19 mortality index were analyzed by dividing the 47 prefectures into two groups at the median level of population size (more populated group [MPG] ≥ 1.6 million and less populated group [LPG] < 1.6 million).

Results

The COVID-19 mortality index (mean 12.7, minimum-maximum: 4.7-25.7) was correlated negatively with the number of physicians per hospital bed (r = -0.386, p = 0.007) and positively with the number of long-term care facilities per 10,000 population (r = 0.397, p = 0.006) and aging rate (the proportion of population aged ≥ 65 years) (r = 0.471, p = 0.001). The two groups varied with respect to the number of physicians (28.7 physicians in the LPG vs. 26.1 physicians in the MPG, p = 0.038) and hospital beds (156 beds in the LPG vs. 119 beds in the MPG, p < 0.001) per 10,000 population. In the multiple regression analysis, the COVID-19 mortality index was correlated negatively with the number of physicians per hospital bed (β = -0.543, p = 0.024) and positively with the aging rate (β = 0.434, p = 0.032) in the LPG, with nonsignificant correlations in the MPG.

Conclusions

The data may suggest a need of improvement in the distribution of physicians and hospital beds in the healthcare system in regions with smaller and older populations to reduce the rate of COVID-19.

The five-year trends in antibiotic prescription by dentists and antibiotic prophylaxis for tooth extraction: a region-wide claims study in Japan

BACKGROUND

Antimicrobial stewardship in dentistry and antibiotic prophylaxis for tooth extraction have been areas of concern in Japan, with limited research available.

METHODS

This cross-sectional study utilized the regional health insurance claims database in Japan to examine antibiotic prescription trends by dentists, including antibiotic regimens, timing of prescription, and days of supply for prophylactic antibiotic use during tooth extraction. Antibiotic prophylaxis for patients with prosthetic heart valves was also investigated.

FINDINGS

Antibiotic prescriptions by dentists decreased by 7% in 2019 compared to those in 2015, with third-generation cephalosporins still accounting for 48.5% in 2019. Amoxicillin prescription increased 3.9 times in 2019, although it only accounted for 8.4% of all antibiotic prescriptions. In 2019, amoxicillin was prescribed for 17.1% of all prophylactic antibiotics associated with tooth extraction, and 80% of prophylactic antibiotics were prescribed for 3 days or more, with 85% prescribed on the day of the procedure. However, only 60-70% of patients with prosthetic heart valves received antibiotic prophylaxis.

INTERPRETATION

Despite the increasing trend after the implementation of the National Action Plan on antimicrobial resistance, the proportion of amoxicillin prescriptions in dentistry remains low. Antimicrobial stewardship issues related to long-term prescription and timing of administration of prophylactic antibiotics for tooth extraction should be addressed. Dentists must recognize the risks associated with high-risk patients with prosthetic heart valves who require antibiotic prophylaxis, and physicians providing valve replacement therapy should inform patients of the requirement for prophylaxis before invasive dental procedures.

Serum chemokine CC-motif ligand 17 is a predictive marker of severe COVID-19 in haemodialysis patients: A retrospective observational study

BACKGROUND

Maintenance haemodialysis (HD) patients are at higher risk for severe coronavirus disease 2019 (COVID-19). Because of a limited number of facilities that can provide inpatient treatment for COVID-19 and HD, it is important to identify HD patients who are at high risk for severe COVID-19. For mild to moderate COVID-19 patients, chemokine CC-motif ligand 17 (CCL17) was reported to be a predictive marker for severe COVID-19; however, the validity of CCL17 among HD patients is unknown.

METHODS

This retrospective observational study enrolled 107 HD patients with mild or moderate COVID-19 at hospitalization (mean age 70.1 ± 15.1 years; 71.0% male). Receiver operating characteristic and logistic regression analyses were used to examine the predictive validity of indices for severe COVID-19.

RESULTS

During hospitalization, 32 patients developed severe COVID-19. Serum CCL17 collected at admission exhibited a higher area under the curve value (0.818) compared with that of other indicators including lactate dehydrogenase and C-reactive protein for the prediction of severe COVID-19. The optimal cut-off value for CCL17 was 150.5 pg/mL. A multi-variate logistic analysis revealed that CCL17 (above 150.5 pg/mL) was significantly associated with severe COVID-19 (Odds ratio, 0.063; 95% Confidence interval [CI], 0.017-0.227; p < .001) even after adjustment for covariates. The addition of the CCL17 to a model consisting of vaccination status, albumin, blood urea nitrogen, C-reacting protein and lactate dehydrogenase significantly improved classification performance for severe COVID-19 using the net reclassification (1.16, 95% CI: 0.82-1.50, p < .001) and integrated discrimination (0.18, 95% CI: 0.09-0.26, p < .001) improvement.

CONCLUSION

CCL17 levels in HD patients with mild or moderate COVID-19 predict risk of developing severe COVID-19.

TRIM27 expression is associated with poor prognosis in sinonasal mucosal melanoma

BACKGROUND

Tripartite motif-containing 27 (TRIM27) has been implicated in the progression of various cancers. However, the role of TRIM27 in sinonasal mucosal melanoma (SNMM) remains poorly understood.

MATERIALS & METHODS

We retrospectively examined 28 patients with SNMM treated with between 2003 and 2021. We undertook immunohistochemical analysis of TRIM27, Ki-67, and p-Akt1 expression in SNMM tissues. We also investigated the relationship between TRIM27 expression and clinical characteristics, prognosis, Ki-67 as a tumor growth potential marker, and p-Akt1 as one of the prognostic factors in mucosal melanoma.

RESULTS

TRIM27 expression was significantly higher in T4 disease than in T3 disease and was higher in stage IV than in stage III. Patients with high-TRIM27 SNMM had a significantly poorer prognosis in terms of overall survival (OS) and disease-free survival.There was also a significantly higher rate of distant metastasis. Univariate analysis for OS revealed that TRIM27 and T classification were significant poor prognostic factors. In addition, the Ki-67 positive score and the p-Akt1 total staining score were significantly higher in the high-TRIM27 group than in the low-TRIM27 group.

CONCLUSIONS

High TRIM27 expression in SNMM was associated with advanced T classification, poor prognosis and distant metastasis. We suggest that TRIM27 has potential as a novel biomarker for prognosis in SNMM.

A case of Behçet's-like disease associated with trisomy 8-positive myelodysplastic syndrome presented periodic fever with MEFV E148Q variant

Behçet's-like disease, which incompletely fulfils the criteria of Behçet's disease, is often associated with trisomy 8-positive myelodysplastic syndrome (MDS). We report a case of an 82-year-old man with these conditions carrying E148Q variant of MEFV gene who presented with periodic fever. The patient presented with joint pain, muscle pain, and episodes of periodic fever every two weeks for the past three months. On admission, painful erythema and fever were observed. Colonoscopy revealed erosion in the cecum and ascending colon. The patient had bicytopenia, and a bone marrow biopsy showed findings compatible with trisomy 8-positive unclassifiable MDS. Because the patient incompletely fulfilled the criteria for Behçet's disease, he was diagnosed with Behçet's-like disease associated with trisomy 8-positive MDS. Positron emission tomography-computed tomography performed during the fever revealed multiple muscle lesions consistent with the sites of pain. To examine the cause of the periodic fever attacks, MEFV gene was analysed, and the results revealed E148Q variant. Steroids were ineffective against periodic fever attacks. A daily dose of 0.5 mg colchicine was prescribed, but the effect was minimal, probably because of the insufficient dose due to renal dysfunction. Based on the diagnosis of atypical familial Mediterranean fever, canakinumab was added, which partially mitigated the periodic fever. This case suggests the importance of ruling out MDS when physicians see an elderly patient who present with Behçet-like disease. Although the significance of E148Q variant in the pathogenesis of periodic fever remains controversial, it may act as a disease modifier in accordance with trisomy 8-positive MDS.

Serum 25-hydroxycholesterol levels are increased in patients with coronavirus disease 2019

BACKGROUND

25-hydroxycholesterol (25HC), produced by cholesterol 25-hydroxylase (CH25H) in macrophages, has been reported to inhibit the replication of viral pathogens such as severe acute respiratory syndrome coronavirus-2. Also, CH25H expression in macrophages is robustly induced by interferons (IFNs).

OBJECTIVE

To better understand the serum level increase of 25HC in coronavirus disease 2019 (COVID-19) and how it relates to the clinical picture.

METHODS

We measured the serum levels of 25HC and five other oxysterols in 17 hospitalized COVID-19 patients.

RESULTS

On admission, 25HC and 27-hydroxycholesterol (27HC) serum levels were elevated; however, 7-ketocholesterol (7KC) levels were lower in patients with COVID-19 than in the healthy controls. There was no significant correlation between 25HC serum levels and disease severity markers, such as interferon-gamma (IFN-γ) and interleukin 6. Dexamethasone effectively suppressed cholesterol 25-hydroxylase (CH25H) mRNA expression in RAW 264.7 cells, a murine leukemia macrophage cell line, with or without lipopolysaccharide or IFNs; therefore, it might mitigate the increasing effects of COVID-19 on the serum levels of 25HC.

CONCLUSIONS

Our results highlighted that 25HC could be used as a unique biomarker in severe COVID-19 and a potential therapeutic candidate for detecting the severity of COVID-19 and other infectious diseases.

Indirect impact of the COVID-19 pandemic on the incidence of non-COVID-19 infectious diseases: a region-wide, patient-based database study in Japan

OBJECTIVES

The COVID-19 pandemic has forced people to change many behaviours, including physical distancing, hygiene measures and lifestyles. This study aimed to evaluate the indirect impact of the COVID-19 pandemic on the incidence of non-COVID-19 infections and medical care costs/visits using health insurance claims.

STUDY DESIGN

This was an observational study using patient-based administrative claims covering approximately 800,000 insured persons and their dependents in the Mie Prefecture in Japan.

METHODS

This study identified non-COVID-19 infectious disease incidences, number of outpatient visits and healthcare costs between 2017 and 2021. Each year was divided into quarters. The adjusted incidence rate ratios (IRRs) during the pandemic (January 2020 to September 2021) and during the prepandemic period (January 2017 to December 2019) were determined using Poisson regression.

RESULTS

The adjusted influenza IRRs from April 2020 were close to zero. The incidence of upper respiratory tract infections and bacterial pneumonia was significantly reduced (IRRs range: 0.39-0.73 and 0.43-0.84, respectively). Gastrointestinal and urinary tract infection incidences decreased by approximately 30% and 10%, respectively. In contrast, sexually transmitted infections (STIs), including syphilis, gonococcal infection and Chlamydia trachomatis infection, did not decrease during the pandemic but increased significantly between April and June 2021 (adjusted IRR, 1.37; 95% confidence interval, 1.18-1.60). The adjusted IRRs for outpatient visits and healthcare costs were 0.86-0.93 and 0.91-0.97, respectively.

CONCLUSIONS

In contrast to other infections, STIs did not decrease during the COVID-19 pandemic. The IRR of STIs during the pandemic period is an area of public health concern. Appropriate screening and medical consultations are strongly recommended.

Disseminated Mycolicibacter arupensis and Mycobacterium avium co-infection in a patient with anti-interferon-γ neutralizing autoantibody-associated immunodeficiency syndrome

BACKGROUND

Disseminated infections of Mycolicibacter arupensis, a slowly growing nontuberculous mycobacteria (NTM) which causes synovitis, osteomyelitis, or pulmonary infections have rarely been reported. We report a case of disseminated M. arupensis and Mycobacterium avium co-infection in a patient with anti-interferon (IFN)-γ neutralizing autoantibody-associated immunodeficiency syndrome.

CASE PRESENTATION

A 68-year-old Japanese male without human immunodeficiency virus infection was referred with complaints of persistent low-grade fever, arthralgia of the upper limbs, and weight loss of 10 kg. Cervical and mediastinal lymphadenopathies as well as a nodular opacity in the right lung were detected, and biopsy specimens of the cervical lymph node yielded M. arupensis without evidence of malignant cells. M. arupensis was also detected in sputum and peripheral blood. Computed tomography (CT) revealed deterioration of the right supraclavicular lymphadenopathy with internal necrosis and multiple low-density splenic lesions. Bone marrow and aspirates from the cervical lymph node collected at initiation of treatment yielded M. avium. The presence of anti-IFN-γ neutralizing autoantibodies was detected, leading to a diagnosis of co-infection of M. arupensis and M. avium with anti-IFN-γ neutralizing autoantibody-associated immunodeficiency syndrome. Post initiation of treatment with clarithromycin, ethambutol, and rifabutin, his fever declined, and his polyarthritis resolved. He developed disseminated varicella zoster during treatment; however, a follow-up CT scan six months after treatment revealed improvement of the lymphadenopathies, consolidation in the right lung, and splenic lesions.

CONCLUSION

This is the first report of disseminated M. arupensis and M. avium co-infection in a patient with anti-IFN-γ neutralizing autoantibody-associated immunodeficiency syndrome.

Monocyte-to-Lymphocyte Ratio in the Diagnosis of Lymphoma in Adult Patients

Background

Lymphomas, including Hodgkin lymphoma and non-Hodgkin lymphoma, are one of the differentials for peripheral lymphadenopathy and are difficult to diagnose clinically. Biopsy is essential for diagnosing lymphoma, although it is invasive. Non-invasive methods are required to identify patients with suspected lymphoma who should undergo a biopsy. The relevance of the monocyte-to-lymphocyte ratio has recently been reported to be a useful diagnostic marker in children with lymphoma and a prognostic marker of various other diseases. This study aimed to determine the relevance of the monocyte-to-lymphocyte ratio in the diagnosis of lymphoma in adults.

Methods

The study included 246 adult outpatients (median age of 49.0 years) presenting with peripheral lymphadenopathy. The final diagnosis was determined by reviewing the medical records. We categorized all patients into either the lymphoma group or the non-lymphoma group. The lymphoma group included patients who underwent biopsy and were diagnosed with lymphoma by histopathology, while the non-lymphoma group included those diagnosed with disease excluding lymphoma. The monocyte-to-lymphocyte ratios were compared between the two groups.

Results

Of the participants, 33 (13.4%) were assigned to the lymphoma group. The median age of the lymphoma and non-lymphoma groups were 67.0 years (interquartile range [IQR] 55.5–75.5 years) and 46.0 years (IQR 36.0–61.0 years), respectively. The lymphocyte and monocyte levels showed no significant differences between the two groups individually. Nonetheless, the monocyte-to-lymphocyte ratio was significantly higher in the lymphoma group (median, 0.36; IQR, 0.24–0.73) than in the non-lymphoma group (median, 0.29; IQR, 0.21–0.43; P = 0.022), independent of lymph node diameter ≥ 1 cm and C-reactive protein levels.

Conclusion

This study suggests that the monocyte-to-lymphocyte ratio can be a helpful diagnostic marker for lymphoma in adults with peripheral lymphadenopathy when the etiology is unclear even after a medical interview and physical examination.

Hemodialysis patients with coronavirus disease 2019: reduced antibody response

BACKGROUND

Because patients on maintenance hemodialysis (HD) have an impaired immune response to pathogens, they are at higher risk of severe coronavirus disease 2019 (COVID-19). However, data on antibody production among HD patients with COVID-19 is scarce. Thus, we performed a retrospective cohort study evaluating severe acute respiratory syndrome coronavirus two antibody (SARS-CoV-2) production within 1 month after COVID-19 onset in hospitalized patients on HD.

METHODS

SARS-CoV-2-specific immunoglobulin (Ig) G levels were quantified using an iFlash 3000 Chemiluminescence Immunoassay analyzer (Shenzhen YHLO Biotech Co., Ltd.) to detect IgG antibodies specific for the S1 subunit of the spike protein (IgG-S1). Propensity score matching was used to balance covariate distribution in HD and non-HD patients. From April 2020 to February 2021, antibody testing was performed on 161 hospitalized patients with symptomatic COVID-19. Of them, 34 HD patients were matched to 68 non-HD patients.

RESULTS

After propensity score matching, the median levels of IgG-S1 in the HD patients at 7-13 days after symptom onset were significantly lower than in non-HD patients, especially in those with severe disease. Among all patients, those with severe disease produced lower levels of IgG-S1 at 7-13 days compared with non-severe patients.

CONCLUSION

COVID-19 patients with severe disease, especially those undergoing HD, had lower IgG-S1 production in the second week of the disease. Thus, the increased risk of severe COVID-19 in HD patients may be, in part, due to a slow and reduced antibody response.

Influenza Outbreak and a Group Meal in a Geriatric Long-term Care Facility in Japan

Influenza outbreaks at geriatric long-term care facilities (g-LTCFs) can be deadly and their prevention is important. However, the factors influencing disease transmission in g-LTCFs remain controversial. In this descriptive study, we tried to identify the potential risk factors influencing influenza outbreaks that occurred in different influenza seasons within a single g-LTCF with 100 residents in Gunma Prefecture. We reviewed the detailed facility records for all influenza cases in both residents and staff between January 2012 and June 2020. Facility preventive measures were also reviewed. We found that community meals may have been a potential source of transmission leading to the outbreaks. When influenza infection is noted, implementation of strict preventive measures and restriction of meal provision to resident rooms may help to prevent disease transmission and the development of an outbreak. Such measures may also be useful to prevent the transmission of other serious droplet-borne diseases within g-LTCFs.

Additional effect of azithromycin over β-lactam alone for severe community-acquired pneumonia-associated acute respiratory distress syndrome: a retrospective cohort study

Background

Community-acquired pneumonia (CAP) is the most common cause of acute respiratory distress syndrome (ARDS). Although previous studies have suggested that macrolide therapy is beneficial for ARDS, its benefit for severe CAP-associated ARDS remains uncertain. Previous studies were limited in that they had a small sample size and included patients with non-pulmonary ARDS and those with pulmonary ARDS. This study aimed to investigate the additional effect of azithromycin when used with β-lactam compared with the effect of β-lactam alone in mechanically ventilated patients with CAP-associated ARDS.

Methods

We identified mechanically ventilated patients with CAP-associated ARDS between July 2010 and March 2015 using data in the Diagnosis Procedure Combination database, a Japanese nationwide inpatient database. We performed propensity score matching analysis to assess 28-day mortality and in-hospital mortality in mechanically ventilated patients with CAP-associated ARDS who received β-lactam with and without azithromycin within hospital 2 days after admission. The inverse probability of treatment weighting analysis was also conducted.

Results

Eligible patients (n = 1257) were divided into the azithromycin group (n = 226) and the control group (n = 1031). The one-to-four propensity score matching analysis included 139 azithromycin users and 556 non-users. No significant difference was observed between the groups with respect to 28-day mortality (34.5% vs. 37.6%, p = 0.556) or in-hospital mortality (46.0% vs. 49.1%, p = 0.569). The inverse probability of treatment weighting analysis showed similar results.

Conclusions

Compared with treatment with β-lactam alone, treatment with azithromycin plus β-lactam had no significant additional effect on 28-day mortality or in-hospital mortality in mechanically ventilated patients with CAP-associated ARDS. To the best of our knowledge, this study is the first to determine the effect of azithromycin in mechanically ventilated patients with CAP-associated ARDS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41479-021-00093-8.

Emergence of Hepatitis C Virus Genotype 2c Infection Among Human Immunodeficiency Virus-Infected Men Who Have Sex With Men in Tokyo, Japan

ABSTRACT

We report on hepatitis C virus genotype 2c infection in 12 human immunodeficiency virus-infected men who have sex with men in Tokyo, Japan. The uncommon strains from the 12 patients were genetically clustered; they suggested an emerging outbreak in this population at high risk of sexually transmitted infections.

Prolonged carriage of ESBL-producing enterobacterales and potential cross-transmission among residents in geriatric long-term care facilities

Previous studies indicated residents in geriatric long-term care facilities (LTCFs) had much higher prevalence of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) carriage than the general population. Most ESBL-E carriers are asymptomatic. The study tested the hypothesis that residents with ESBL-E carriage may accumulate inside geriatric LTCFs through potential cross-transmission after exposure to residents with prolonged ESBL-E carriage. 260 residents from four Japanese LTCFs underwent ESBL-E testing of fecal specimens and were divided into two cohorts: Cohort 1,75 patients with ≥ 2 months residence at study onset; Cohort 2, 185 patients with < 2 months residence at study onset or new admission during the study period. Three analyses were performed: (1) ESBL-E carriage statuses in Cohort 1 and Cohort 2; (2) changes in ESBL-E carriage statuses 3-12 months after the first testing and ≥ 12 months after the second testing; and (3) lengths of positive ESBL-E carriage statuses. Compared with the residents in Cohort 1, a significantly larger proportion of residents in Cohort 2 were positive for ESBL-E carriage (28.0% in Cohort 1 vs 40.0% in Cohort 2). In the subsequent testing results, 18.3% of residents who were negative in the first testing showed positive conversion to ESBL-E carriage in the second testing, while no patients who were negative in the second testing showed positive conversion in the third testing. The maximum length of ESBL-E carriage was 17 months. The findings indicated that some residents acquired ESBL-E through potential cross-transmission inside the LTCFs after short-term residence. However, no residents showed positive conversion after long-term residence, which indicates that residents with ESBL-E carriage may not accumulate inside LTCFs. Practical infection control and prevention measures could improve the ESBL-E prevalence in geriatric LTCFs.

Recurrent Aseptic Meningitis Associated with Kikuchi's Disease (Histiocytic Necrotizing Lymphadenitis): A Case Report and Literature Review

We herein report a 31-year-old man with recurrent aseptic meningitis associated with Kikuchi's disease. Although aseptic meningitis is the most common neurological complication of Kikuchi's disease, its characteristics remain unclear, especially in recurrent cases. A literature review revealed that aseptic meningitis associated with Kikuchi's disease was more likely to occur in men and was associated with a low cerebrospinal fluid (CSF)/serum glucose ratio. Lymphadenopathy tended to occur simultaneously or after the onset of meningitis. When encountering a patient with aseptic meningitis of unknown etiology, it may be worthwhile to focus on the CSF/serum glucose ratio and lymphadenopathy with a careful examination.

Outcomes associated with treatment change from tenofovir disoproxil fumarate to tenofovir alafenamide in HIV-1-infected patients: a real-world study in Japan

OBJECTIVES

To investigate the impact of switching from tenofovir disoproxil fumarate (TDF)- to tenofovir alafenamide (TAF)-containing regimens on bone, kidney, serum lipids and body weight among Asian patients.

METHODS

A prospective, multicentre, observational cohort study was conducted at three centres for HIV infection in Japan during 2017-2019. HIV-infected adults previously treated with TDF-containing regimens and scheduled to switch to TAF-containing regimens were included. Bone mineral density (BMD), renal markers, lipids and weight were measured consecutively from 12 months before to 12 months after the switch.

RESULTS

Among 118 patients evaluated, the mean percentage change to spine BMD during 1 year of TAF treatment was higher than that during 1 year of TDF treatment (mean difference = 1.9%; 95% confidence interval (CI): 0.8-3.1). Urine protein and β₂ -microglobulin levels decreased significantly after the switch, while low-density lipoprotein cholesterol and triglycerides increased. During the TDF and TAF periods, the mean weight gains were 0.2 and 1.9 kg, respectively (mean difference = 1.6 kg; 95% CI: 0.9-2.3). Subgroup analysis revealed a significant difference between the mean body weight change associated with an integrase inhibitor (INSTI) (+2.8 kg) and that associated with a non-INSTI (+1.2 kg) third agent treatment only during the TAF period.

CONCLUSIONS

Among predominantly Japanese HIV-infected patients, BMD and renal tubular markers improved, while lipid profiles worsened significantly after the switch. Weight gain during the TAF period was larger than that during the TDF period. Concurrent use of INSTI with TAF may act synergistically to gain body weight.

Breast tuberculosis presenting with intractable mastitis: a case report

Background

Breast tuberculosis, also known as tuberculous mastitis, is an extremely rare form of tuberculosis. It accounts for <0.1% of all breast diseases and <2% of all cases of tuberculosis. It is often misdiagnosed as breast cancer, which can potentially lead to a delayed diagnosis.

Case presentation

A 69-year-old Japanese woman presented with a tumor-mimicking lesion in her right breast, followed by intractable mastitis with a fistula formation. The time until the correct diagnosis of tuberculosis of the breast and sternal bone was 14 months.

Conclusions

Although rare, it is important to recognize that tuberculous mastitis can present as refractory abscesses/mastitis or mass lesions that mimic carcinomas in women of reproductive age and elderly people. Breast tuberculosis should always be considered in the differential diagnoses, particularly in patients with a history of tuberculosis and those living in areas where tuberculosis is endemic.

Association between length of residence and prevalence of MRSA colonization among residents in geriatric long-term care facilities

Background

A high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization has been reported among residents in geriatric long-term care facilities (LTCFs). Some studies indicate that MRSA might be imported from hospitals into LTCFs via resident transfer; however, other studies report that high MRSA prevalence might be caused by cross-transmission inside LTCFs. We aimed to assess which factors have a large impact on the high MRSA prevalence among residents of geriatric LTCFs.

Methods

We conducted a cohort study among 260 residents of four geriatric LTCFs in Japan. Dividing participants into two cohorts, we separately analyzed (1) the association between prevalence of MRSA carriage and length of LTCF residence (Cohort 1: n = 204), and (2) proportion of residents identified as MRSA negative who were initially tested at admission but subsequently identified as positive in secondary testing performed at ≥2 months after their initial test (Cohort 2: n = 79).

Results

Among 204 residents in Cohort 1, 20 (9.8%) were identified as positive for MRSA. Compared with residents identified as MRSA negative, a larger proportion of MRSA-positive residents had shorter periods of residence from the initial admission (median length of residence: 5.5 vs. 2.8 months), although this difference was not statistically significant (p = 0.084). Among 79 residents in Cohort 2, 60 (75.9%) were identified as MRSA negative at the initial testing. Of these 60 residents, only one (1.7%) had subsequent positive conversion in secondary MRSA testing. In contrast, among 19 residents identified as MRSA positive in the initial testing, 10 (52.6%) were negative in secondary testing.

Conclusions

The prevalence of MRSA was lower among residents with longer periods of LTCF residence than among those with shorter periods. Furthermore, few residents were found to become MRSA carrier after their initial admission. These findings highlight that MRSA in LTCFs might be associated with resident transfer rather than spread via cross-transmission inside LTCFs.

Influenza vaccination coverage in Chiburijima Island, Japan: Impact of diversification of vaccination place

BACKGROUND

To increase the influenza vaccination rate in Chiburijima Island, we diversified vaccination places from a single clinic to the seven town halls from all the districts.

METHODS

We retrospectively analyzed influenza vaccination coverage, vaccinees' district of residence, and location of vaccination place, from prevaccination screening questionnaires between October 2007 and March 2018. Except for home-visiting vaccination services, before 2011, influenza vaccination was provided only at a single clinic; after 2012, it was provided at the seven town halls in addition to the clinic. We calculated the vaccination rates among residents of Chiburijima Island, stratified by age groups and districts of residence.

RESULTS

Estimated influenza vaccination rates for all ages increased from 38% in 2007 to 58% in 2017. There was a 14% increase in coverage in 2010 (the year following the 2009 H1N1 pandemic) and a slight increasing trend after 2012. The vaccination coverage of residents, particularly of people ≥65 years old and living >1 km from the former vaccination place, increased after diversification of the vaccination place.

CONCLUSIONS

Influenza vaccination rate in Chiburijima Island increased by 20% between 2007 and 2017, although the rate among the elderly Japanese people decreased by 4% based on the national data of routine immunization. Shortening the distance to vaccination places might improve the coverage as elderly people are often restricted due to transportation means. Sustained and multifaceted strategies are necessary for better immunization coverage.

Predictive variables for hemodialysis and death in Japanese spotted fever, and the association between distance from rivers and incidence

The number of patients with Japanese spotted fever (JSF) and its case fatality rate have been increasing in Japan and other East Asian countries. Better clinical and laboratory biomarkers are needed to avoid misdiagnosing JSF and to predict severe cases. In addition to determining these predictors, we aimed to examine the association between the incidence of JSF and the distance from rivers, in Hiroshima Prefecture, one of the most JSF prevalent areas in Japan. Patients diagnosed with JSF from 2009 to 2017 in two hospitals in Onomichi City in Hiroshima Prefecture were studied, and their clinical characteristics and laboratory data were collected retrospectively from medical charts. A random forest was used to identify predictors of severe JSF leading to hemodialysis or death. A multivariable negative binomial regression model was utilized to analyze the association between the cumulative incidence in each postal code area and the distance from the residential postal code area to the closest river. Out of 82 patients with JSF (mean age at diagnosis, 74.1 ± 10.6 years; 34 (41.5 %) men), 6 cases were regarded as severe (among them 5 hemodialysis patients and 3 deaths). Twenty-eight (34.1 %) patients were misdiagnosed at least once at the initial hospital visit. Laboratory examination showed 34.5 % had atypical lymphocytes, 73.8 % had no eosinophils, 75.6 % had an elevated aspartate aminotransferase (AST) level, and 69.5 % had hyponatremia. Among cases without urine leucocytes, 63.3 % had proteinuria and 63.3 % had hematuria. Low serum total protein was the strongest predictor of severe JSF, followed by high blood urea nitrogen (BUN) and low albumin. Geospatial analysis showed a significant negative association between the cumulative incidence of JSF cases and the distance from rivers in an adjusted model: the cumulative incidence decreased by 0.51 times (95 % CI: 0.30 to 0.86) for every kilometer of distance from the residential postal code area to the closest river. Some laboratory data may be useful in averting misdiagnosis of JSF and in predicting severe cases. Additional studies should be done in order to clarify the mechanism and association of the incidence of JSF with the distance from the nearest river.

Histamine-2 receptor antagonists versus proton pump inhibitors for septic shock after lower gastrointestinal tract perforation: a retrospective cohort study using a national inpatient database

Background

Studies have shown the potential benefit of stress ulcer prophylaxis including histamine-2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) in critically ill patients. However, the adverse effects of stress ulcer prophylaxis such as Clostridioides difficile infection (CDI) and hospital-acquired pneumonia have been reported. Abdominal septic shock is associated with increased risk of bleeding, CDI, and pneumonia; however, which ulcer prophylaxis might be associated with better outcomes in patients with septic shock after lower gastrointestinal tract perforation is unknown.

Methods

In this retrospective cohort study using the Japanese Diagnosis Procedure Combination database from July 2010 to March 2015, we identified patients aged 18 years or older who received open abdominal surgery for lower gastrointestinal tract perforation and who used vasopressors and antibiotics within 2 days of admission. We performed propensity score matching and inverse probability of treatment weighting (IPTW) to compare the outcomes between patients who received H2RA and those who received PPI within 2 days of admission. The outcomes included gastrointestinal bleeding requiring endoscopic hemostasis within 28 days of admission, 28-day mortality, CDI, and hospital-acquired pneumonia.

Results

The propensity score matching created 1088 pairs of patients who received H2RA or PPI within 2 days of admission. There were no significant differences between the H2RA and PPI groups regarding gastrointestinal bleeding requiring endoscopic hemostasis within 28 days of admission (0.74% vs 1.3%, risk ratio 0.57 (0.24–1.4), and P = 0.284), 28-day mortality (11.3% vs 12.9%, risk ratio 0.88 (0.68–1.1), and P = 0.386), CDI (0.64% vs 0.46%, risk ratio 1.4 (0.45–4.4), and P = 0.774), and hospital-acquired pneumonia (3.0% vs 4.3%, risk ratio 0.70 (0.45–1.1), and P = 0.138). IPTW analysis showed similar results.

Conclusions

There were no significant differences in gastrointestinal bleeding requiring endoscopic hemostasis within 28 days of admission, 28-day mortality, CDI, and hospital-acquired pneumonia between H2RA and PPI in patients with septic shock after lower gastrointestinal tract perforation.

Gram-negative Organisms from Patients with Community-Acquired Urinary Tract Infections and Associated Risk Factors for Antimicrobial Resistance: A Single-Center Retrospective Observational Study in Japan

A specific antibiogram is necessary for the empiric antibiotic treatment of community-acquired urinary tract infections (UTI) because of the global spread of antimicrobial resistance. This study aimed to develop an antibiogram specific for community-acquired UTI and assess the risk factors associated with community-acquired UTI caused by antimicrobial-resistant organisms. This cross-sectional observational retrospective study included patients with community-acquired UTI caused by Gram-negative rods (GNR) who were admitted to the emergency department at a tertiary care hospital in Ibaraki, Japan, in 2017–2018. A total of 172 patients were enrolled (including 38 nursing home residents). Of the 181 GNR strains considered as causative agents, 135 (75%) were Escherichia coli, and 40 (22%) exhibited third-generation cephalosporin resistance. Extended-spectrum β-lactamase (ESBL)-producing E. coli accounted for 25/40 (63%) of resistant GNR. Overall susceptibility rate of Enterobacterales was 92%, 81%, 100%, 75%, and 89% for cefmetazole, ceftriaxone, meropenem, levofloxacin, and trimethoprim–sulfamethoxazole, respectively. Residence in a nursing home (odds ratio (OR), 2.83; 95% confidence interval (CI), 1.18–6.79) and recent antibiotic use (OR, 4.52; 95% CI, 1.02–19.97) were independent risk factors for UTI with resistant GNR. ESBL-producing E. coli was revealed to have a strong impact on antimicrobial resistance pattern. Therefore, an antibiotic strategy based on a disease-specific antibiogram is required.

The effect of antithrombin added to recombinant human-soluble thrombomodulin for severe community-acquired pneumonia-associated disseminated intravascular coagulation: a retrospective cohort study using a nationwide inpatient database

Background

Studies showed potential benefits of recombinant human-soluble thrombomodulin (rhTM) and antithrombin for treating sepsis associated disseminated intravascular coagulation. However, benefits of their combination have been inconclusive.

Methods

Using a nationwide inpatient database in Japan, we performed propensity-score matched analyses to compare outcomes between rhTM combined with antithrombin and rhTM alone for severe community-acquired pneumonia associated disseminated intravascular coagulation from July 2010 to March 2015. The outcomes included in-hospital mortality and requirement of red cell transfusion.

Results

Propensity score matching created 189 pairs of patients who received rhTM combined with antithrombin or rhTM alone within 2 days of admission. There was no significant difference between the two groups for in-hospital mortality (40.2% vs. 45.5%). Patients treated with rhTM and antithrombin were more likely to require red cell transfusion than those treated with rhTM alone (37.0% vs. 25.9%).

Conclusions

Compared with rhTM alone, combination of rhTM with antithrombin for severe community-acquired pneumonia-associated disseminated intravascular coagulation may be ineffective for reducing mortality and may increase bleeding.

Indications and classes of outpatient antibiotic prescriptions in Japan: A descriptive study using the national database of electronic health insurance claims, 2012-2015

OBJECTIVES

To evaluate condition-specific antibiotic prescription rates and the appropriateness of antibiotic use in outpatient settings in Japan.

METHODS

Using Japan's national administrative claims database, all outpatient visits with infectious disease diagnoses were linked to reimbursed oral antibiotic prescriptions. Prescription rates stratified by age, sex, prefecture, and antibiotic category were determined for each infectious disease diagnosis. The proportions of any antibiotic prescription to all infectious disease visits and the proportions of first-line antibiotic prescriptions to all antibiotic prescriptions were calculated for each infectious disease diagnosis.

RESULTS

Of the 659 million infectious disease visits between April 2012 and March 2015, antibiotics were prescribed in 266 million visits (704 prescriptions per 1000 population per year). Third-generation cephalosporins, macrolides, and quinolones accounted for 85.9% of all antibiotic prescriptions. Fifty-six percent of antibiotic prescriptions were directed toward infections for which antibiotics are generally not indicated. The diagnoses with frequent antibiotic prescription were bronchitis (184 prescriptions per 1000 population per year), viral upper respiratory infections (166), pharyngitis (104), sinusitis (52), and gastrointestinal infection (41), for which 58.3%, 40.6%, 58.9%, 53.9%, and 26.1% of visits antibiotics were prescribed, respectively. First-line antibiotics were rarely prescribed for pharyngitis (8.8%) and sinusitis (9.8%). More antibiotics were prescribed for children aged 0-9 years, adult women, and patients living in western Japan.

CONCLUSIONS

Antibiotic prescription rates are high in Japan. Acute respiratory or gastrointestinal infections, which received the majority of the antibiotics generally not indicated, should be the main targets of antimicrobial stewardship intervention.

Histological evidence for the cardiac safety of high-dose pegylated liposomal doxorubicin in a patient with HIV-associated Kaposi sarcoma: a case report and literature review

Background

Pegylated liposomal doxorubicin plays an important role in the treatment of patients with severe refractory human immunodeficiency virus (HIV)-associated Kaposi sarcoma (KS). High cumulative doses of conventional doxorubicin exceeding 500 mg/m² are known to cause cardiac toxicity. However, the safe cumulative dose of pegylated liposomal doxorubicin is unclear.

Case presentation

A 40-year-old Japanese man with HIV infection presented with pain, edema, and multiple skin nodules on both legs which worsened over several months. He was diagnosed with HIV-associated KS. He received long-term pegylated liposomal doxorubicin combined with antiretroviral therapy for advanced, progressive KS. The cumulative dose of pegylated liposomal doxorubicin reached 980 mg/m². The patient’s left ventricular ejection fraction remained unchanged from baseline during treatment. After he died as a result of cachexia and wasting, caused by recurrent sepsis and advanced KS, an autopsy specimen of his heart revealed little or no evidence of histological cardiac damage. We also conducted a literature review focusing on histological changes of the myocardium in patients treated with a cumulative dose of pegylated liposomal doxorubicin exceeding 500 mg/m².

Conclusions

This case report and literature review suggest that high (> 500 mg/m²) cumulative doses of pegylated liposomal doxorubicin may be used without significant histological/clinical cardiac toxicity in patients with HIV-associated KS.